Analysis Bridge Resource Management Principles - Stellanova The essence of BRM is the effective use of all available human and physical resources to complete an operation safely. BRM addresses issues such as vigilance and people's attitude towards managing operational tasks, stress, and risks. Optimizing the management of these elements has a direct impact on the following four factors critical to the successful outcome of any operation: situational awareness - recognizing and defining the nature of the problem; metacognition - reflecting on and judging one's own cognitive activities or decisions; shared mental models - involving others in the problem-solving process; and resource management - understanding tasks to be performed, their priorities, and required and available resources. Although the master of the Stellanova was acting as the officer of the watch and was therefore responsible for navigation, he was doing administrative tasks for some of the time the vessel was navigating in the confined waters of the South Shore Canal. In the crucial seconds before the first sheer, only the pilot had a clear mental model of where the ship was in relation to the channel and to the downbound CanadianProspector. As the master was not actively sharing the conning position with the pilot nor was he actively involved in the navigation of the vessel, the environment on the bridge was not conducive to promoting good communications or a shared mental model. Just before the first sheer, the master was preoccupied with trying to find the sticks on the chart. Once the sheer had begun, helm orders were still given by the pilot, but pitch control was now assumed by the master. Just before the collision, pitch control was again assumed by the pilot. Keeping a close watch on the movement of a vessel is key to safe navigation in confined waters and is a very important factor for the execution of manoeuvres. It is therefore essential that each member of the bridge team clearly understands his/her role and ensures that all information relating to the conduct of the vessel is conveyed to other team members. This was not done. Non-observance of the principles of BRM such as the absence of effective communication or the lack of a shared mental model have been identified in past TSB reports as a contributing factor in several occurrences. We note that these conditions persisted on the Stellanova even though both key members of the bridge team had received BRM training. Loss of Control of the Stellanova In close quarters, close watch of the movement of a vessel must be kept to ensure vessel safety. In order to do this, the bridge team must be familiar with the operation of all on-board navigation equipment and be cognizant of the limitations of the equipment. Shortly after reducing the pitch setting of the Stellanova with the variable-pitch control lever, the pilot realized that the vessel had moved closer to the south side of the channel. From that point on, the bridge team performed manoeuvres but did not succeed in regaining control of the vessel. Vessels with variable-pitch propellers have a tendency to go off course if the propeller pitch is reduced too quickly.4 The control lever on the Stellanova is relatively small and has no detents for each gradient. It is therefore difficult to accurately set the propeller pitch at a specific gradient especially at night and during a rapidly developing situation. Since the Stellanova has a tendency to yaw unpredictably to port or starboard when the propeller pitch is decreased quickly, and since the propeller pitch was reduced before the vessel sheered, the difficulties associated with the setting of the gradient may, in part, account for the vessel's behaviour prior to the occurrence. The suction effect on the banks is analogous to squat, except that it works in the horizontal plane rather than the vertical plane. When a vessel moves through the middle of a shallow channel, the flow of water on either side of the hull is more or less symmetrical, and the control and response of the rudder are not affected. However, when the vessel tracks parallel to but not on the centreline of a shallow and confined channel, the flow of water between the vessel and the near bank accelerates, causing a reduction in pressure, and the vessel is drawn towards the near bank. The strength of the suction effect depends largely on the speed of the vessel, the depth of the water, and how close the vessel is to the bank. When a vessel is subject to such a suction effect, the best practice to extricate the vessel from the situation is to reduce speed. In this occurrence, the propeller pitch was increased to neutralize the sheer. The subsequent sheer to starboard is similar to the bank suction effect. In this instance, the vessel's wheelhouse was well forward and the blue (steering) light was not a good visual reference for observing vessel movement. Consequently, a view of the stern was essential to maintain a better appreciation of the vessel's behaviour/response. As the wheelhouse and chart room arrangements restricted view aft, cues necessary to maintain visual reference and situational awareness were not readily available from the conning position. This made navigation from the central conning position more difficult. It is possible that the Stellanova sheered towards the south side of the South Shore Canal due to a reduction in thrust in conjunction with the difficulties associated with vessel ergonomics. In confined waters, there is little margin for error, and the onset of sheering would make regaining control of a vessel difficult. Consequently, close coordination between the pilot and the master and close monitoring of the vessel's progress by both is essential to ensure a comprehensive and shared mental model. Following the sheer to port, the vessel could not be steadied in the centre of the channel. This would suggest that there was ineffective coordination between the pilot and the master - the master having in-depth understanding of the vessel's manoeuvring characteristics and the pilot having extensive local knowledge. The pilot had some experience on vessels fitted with Becker rudders under normal operating conditions, unassociated with emergency situations. Manoeuvres by the CanadianProspector After the CanadianProspector had entered the South Shore Canal, it had to maintain sufficient speed to be able to steer. Since there was not enough room to manoeuvre, a collision could not be avoided by the two vessels. Evaluation of Conduct on the CanadianProspector Information gathered during the investigation indicates that the principles of BRM were applied on the CanadianProspector. Communication Between Vessels It is the responsibility of mariners to use the radio frequencies that are monitored by the traffic regulator. To manage traffic, the regulator must assess the traffic situation as a whole and must therefore be advised of all transmissions concerning navigation. Communications between the Stellanova and the CanadianProspector were on VHF channel 8, which is not monitored by St. Lawrence Seaway traffic regulators. It is possible that the Stellanova sheered towards the south side of the South Shore Canal due to a reduction in thrust in conjunction with vessel ergonomics. The Stellanova's master was not actively involved in the navigation of the vessel during the transit, and the environment on the bridge was not conducive to promoting good communications or a shared mental model. Due to the bank suction effect on the south side of the channel, the Stellanova sheered a second time towards the middle of the channel. The CanadianProspector did not have enough manoeuvring room to avoid the impact.Findings as to Causes and Contributing Factors It is possible that the Stellanova sheered towards the south side of the South Shore Canal due to a reduction in thrust in conjunction with vessel ergonomics. The Stellanova's master was not actively involved in the navigation of the vessel during the transit, and the environment on the bridge was not conducive to promoting good communications or a shared mental model. Due to the bank suction effect on the south side of the channel, the Stellanova sheered a second time towards the middle of the channel. The CanadianProspector did not have enough manoeuvring room to avoid the impact. Communications related to navigational safety are effected on frequencies that are not monitored by the Seaway.Finding as to Risk Communications related to navigational safety are effected on frequencies that are not monitored by the Seaway. Although some mariners are trained in bridge resource management (BRM), the principles of BRM are not fully put into practice. The pilot had not received hands-on training on similar vessels in non-threatening environments or in emergency situations. This training could have led to a better appreciation of non-traditional ship-handling characteristics and evasive manoeuvres.Other Findings Although some mariners are trained in bridge resource management (BRM), the principles of BRM are not fully put into practice. The pilot had not received hands-on training on similar vessels in non-threatening environments or in emergency situations. This training could have led to a better appreciation of non-traditional ship-handling characteristics and evasive manoeuvres.